PSYCHIATRY AND FAMILY COUNSELING, LLP Leominster Westborough Worcester

Transcription

1 PSYCHIATRY AND FAMILY COUNSELING, LLP Leominster Westborough Worcester Patient Information Form Last Name: First Name: Birth Date: Street Address: Apartment: City: State: Zip Code: Home Telephone: Mobile Telephone: Age: Office Telephone: Gender: Occupation: Employer: Social Security Number: How did you hear about us? Please identify: Primary Care Physician: friend or family website other physician directory listing Primary Care Physician phone number: other therapist article or publication presentation or other workshop Emergency Contact Last Name: First Name: Relationship: Home Telephone: Mobile Telephone: Legal Guardian (if patient is a minor) Last Name: First Name: Birth Date: Home Telephone: Mobile Telephone: Age: Office Telephone: Gender: Occupation: Social Security Number:

2 Child s School: Grade: Teacher: Any Special Education Services? Y N If yes, describe: If child has been retained a grade, which grade? Child s Physician: Phone: Any medical conditions or allergies? Who referred you? Please list any medications and doses your child takes: Please list child s parents/or step-parents: Name: Age: Relationship Address(if different from child) Home #: Work #: Occupation: Please list child s siblings and/or step-siblings: Name Relationship Age Are any of the children in the family adopted? If your child has seen other therapists in the past, Please list names of professionals and approximate dates: Are there any important or pending legal problems, such as any difficulties with the law, custody problems, etc.? Y N If so, please describe these problems: Has the patient ever been on any psychiatric medication? Y N If yes, please list medication(s) and dose Which medication is currently being taken and at what dose: Has the potential patient ever been hospitalized for psychiatric reasons? Y N If yes, when was the last hospitalization? Please briefly describe the nature of the problem which you are seeking services for:

3 Insurance Information Insured s last name: Insured s first name: Birth date: Insurance company: Phone: Address: State: Zip code: Subscriber ID number: Group number: copay amount: I, as the insured individual named above, give Psychiatry and Family Counseling, LLP permission to file my information and request payment. I understand that I am responsible for all charges not paid by the insurance or managed care company. Signature: Date:

4 Pg 2 INTRODUCTION Welcome to Psychiatry and Family Counseling, LLP. Our website contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of your first session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.

5 Pg 3 PSYCHIATRY AND FAMILY COUNSELING, LLP Office Policy Please familiarize yourself with our office policies. If you have any questions, please call our office or your doctor. Insurance Cancellations 1. Patients are responsible for being aware of 1. Because your appointment time current insurance coverage. This includes the has been reserved for you, details of: you will be charged for Out of network benefits cancellations with less than 48 Deductible and/or out-of-pocket hours (2 business days)notice. Need for pre-certification For example, if your appointment is Current coverage and copayment scheduled on a Monday or following a Maximum annual visits long weekend, please call on the Current visits remaining preceding Friday. Any changes in coverage 2. Charges for missed appointments are 2. If you have exceeded your benefits covered you not covered by your insurance and are are responsible for the full payment for any due and payable prior to any further uncovered sessions. appointments. Please note that such charges include the amount normally 3. Your mental health coverage may be carved covered by the insurance company in out to other managed care companies although addition to the copay amount. this is rare, we may be considered out-of-network with those companies. Telephone Calls 1. Please leave your full name and phone 4. Please note that your insurance may place limits on number with your message. Please leave the number of visits allowed per calendar year. This the best time of day to call. may not be sufficient to cover the clinically appropriate level of care determined by your doctor. Payment 1. Payment is expected at the time of Medications appointment. We accept cash or check. 1. To ensure quality care, regular follow up with routine 2. Requests for written reports or records office visits is necessary for prescriptions to be provided. may incur additional charges. 3. There is a $50 charge for returned checks 2. Please inform your physician about needed refills at least 3 business days before your medication runs out. Set aside an emergency reserve of 3 to 5 days of each prescription. Office Policy Patient Acknowledgement Patient Name: Birth Date: I have received a copy of the office policy of Psychiatry and Family Counseling, LLP and agree to the terms within.

6 Signature: Date: Relationship to patient (if signed by authorized representative) Parent Legal Guardian other Psychiatry and Family Counseling, LLP Leominster Westborough Worcester Notice of HIPAA Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review if carefully I. Our Responsibility ~ Health oversight activities The confidentiality of your personal health ~ In response to legal proceedings information is very important to us. Your ~ Other covered entities payment health information includes records that we activities create and obtain when we provide you care. ~ Other covered entities healthcare it also includes bills, insurance claims, or other operations activities to the extent payment information that we maintain related permitted under HIPAA to your care. ~ Other healthcare providers treatment activities This Notice describes how we handle your ~ Other public health activities health information and your rights regarding ~ To prevent a serious threat to public this information. Generally speaking, we are health or safety required to maintain the privacy of your health ~ To workers compensation or similar information as required by law; provide you with programs for processing of claims this Notice of our duties and privacy practices ~ Uses and disclosures required by law regarding the health information about you that we ~ Uses and disclosures required by law collect and maintain; and follow the terms of our Notice for unempancipated minors currently in effect. ~ Uses and disclosures in domestic violence or neglect situations II. Contact Information After reviewing this Notice, if you need further V. Any Other Use or Disclosure information or want to contact us for any reason Before using or disclosing your personal regarding the handling of your health information health information for any other purpose please direct any communications to your therapist. not identified above, we will obtain your written authorization. Unless III. Uses and Disclosures of Information action has already been taken in Under federal law, we are permitted to use and compliance with the authorization by disclose personal health information without submitting your written request to us. authorization for treatment, payment, and health care operations. Participants in this organized VI. Your Health Information Rights health care arrangement also share health ~ Request that we restrict certain uses information with each other, as necessary to carry and disclosures of your health out treatment, payment, or health care operations information; we are not, however, We may share the minimum amount of personal required to agree to a requested health information necessary for business restriction. associates performing services on our behalf. ~ Request that we communicate with IV. Other Uses and Disclosures you by alternative means, such as As required by the Food & Drug Administration making records available for pick-up

7 As required during an investigation by law or mailing them to you at an alternative enforcement agencies address, such as a P.O. Box. We will accommodate reasonable requests for such confidential communications. ~ Request to review, or to receive a copy of, the VII. To Request Information or File a health information about you that is maintained complaint in our files and the files of our business If you believe your privacy rights have been associates. We reserve the right to charge a fee for violated, you may file a written complaint the costs of copying, mailing or other supplies by mailing it or delivering it to our contact associated with your request. If we are unable to person. You may complain to the Secretary satisfy your request, we will tell you in writing the of Health and Human Services (HHS) by reason for the denial and your right, if any, to writing to Office for Civil Rights, U.S. Dept request a review of the decision. Of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, ~ Request that we amend the health information HHH Building, Washington D.C ; by about you that is maintained in our files and the calling 1-(800) ; or by sending an files of our business associates. Your request must to OCRprivacy@hhs.gov. We cannot, explain why you believe our records require and will not, make you waive your right to amendment. If we are unable to satisfy your request, file a complaint as a condition of receiving we will tell you in writing the reason for the denial and care from us, or penalize you for filing a tell you how you may contest the decision, including complaint your right to submit a statement disagreeing with the decision. This statement will be added to your records. VIII. Revisions to this Notice We reserve the right to amend the terms of ~ Request a list of our disclosures of your health this Notice. If this Notice is revised, the information. This list, known as an accounting of amended terms shall apply to all health disclosures, will not include certain disclosures, such as information that we maintain, including those made for treatment, payment, or health care information about you collected or obtained operations. We will provide you the accounting free of before the effective date of the revised charge, however, if you request more than one accounting Notice. If the revisions reflect a material in any 12 month period, we may impose a reasonable, cost- change to the use and disclosure of your based fee for any subsequent request. Your request should information, your rights regarding such indicate the period of time in which you are interested. We information, our legal duties, or other will be unable to provide you an accounting for any privacy practices described in the Notice, we disclosures made before will promptly distribute the revised Notice, post it in the waiting area of our offices, ~ Request a paper copy of this Notice. make copies available to our patients and others, and post it on our website. In order to exercise any of your rights described above, you must submit a written request to our office. If you have questions about your rights, please speak with our contact person, available by phone or during normal office hours. Privacy Practice Patient Acknowledgement Patient Name: Birth Date: I acknowledge that I have received a copy of the Notice of Privacy Practices of Psychiatry and Family Counseling. The Notice provides in detail the uses and disclosures of my protected health information that

8 may be made by this practice, my individual rights, how I may exercise these rights, and the practice s legal duties with respect to my information. Signature: Date: Relationship to patient (if signed by authorized representative) parent legal guardian other Psychopharmacology (medication) with Children and Adolescents At times, the use of medication is helpful with children and teenagers with certain emotional and psychological problems. The evaluation process will determine who would benefit from this approach. When we recommend medication, it is always done in combination with psychotherapy. Our psychiatrist and clinical nurse specialists are specifically trained in child and adolescent psychopharmacology. Some of the areas where medication may be indicated include: Attention Deficit Disorders, Depression, Anxiety Disorders, including Obsessive Compulsive Disorder and Bipolar Disorder. This approach is always done with careful consideration and clear explanations of benefits and risks.